<!DOCTYPE html>
<html>
<meta charset="utf-8">
<head th:include="include :: header">
</head>
<body class="gray-bg">
<div class="wrapper wrapper-content ">
    <div class="row">
        <div class="col-sm-12">
            <div class="ibox float-e-margins">
                <div class="ibox-content">
                    <form class="form-horizontal m-t" id="signupForm">
                        <div class="form-group">
                            <label class="col-sm-3 control-label">订单流水号：</label>
                            <div class="col-sm-8">
                                <input id="orderId" name="orderId" class="form-control" type="text" maxlength="32"
                                       required>
                            </div>
                        </div>
                        <div class="form-group">
                            <label class="col-sm-3 control-label">药品是否有问题：</label>
                            <div class="col-sm-8">
                                <label class="radio-inline"> <input name="hasProblem" type="radio" value="true"
                                                                    id="hasProblem0" checked="checked"/>
                                    是
                                </label> <label class="radio-inline"> <input name="hasProblem" type="radio"
                                                                             value="false" id="hasProblem1"/>
                                否
                            </label>
                            </div>
                        </div>
                        <div class="form-group">
                            <label class="col-sm-3 control-label">原因备注：</label>
                            <div class="col-sm-8">
                                <textarea id="comment" name="comment" class="form-control" required></textarea>
                            </div>
                        </div>
                        <!-- -->
                        <div class="form-group">
                            <div class="col-sm-8 col-sm-offset-3">
                                <button type="submit" class="btn btn-primary">提交</button>
                            </div>
                        </div>
                    </form>
                </div>
            </div>
        </div>
    </div>
</div>
<div th:include="include::footer"></div>
<script type="text/javascript" src="/js/appjs/app/sale/back.js"></script>
</body>
</html>
